Development of Plain Language Quality of Care Hospital Outpatient Measures for the Medicare Population

Theoretical Background and research questions/hypothesis: In the years since the Balanced Budget Act of 1997 (BBA), the Centers for Medicare & Medicaid Services (CMS) has added a number of comparative quality tools to its consumer websites. These tools provide public accountability for the quality of care offered by healthcare providers, encourage quality improvement, and inform consumers about their health care options. Subsequent legislation (such as the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005) has directed CMS to format these tools in a manner that an average beneficiary can understand and use when choosing health care providers. CMS recently established the Hospital Outpatient Department Quality Reporting Program (HODQRP), under which hospitals will report data on quality of care in outpatient settings. For this new program, CMS identified new quality measures around Acute Myocardial Infarction (AMI) and chest pain care, surgical care, and diagnostic imaging efficiency. These new measures as will be included on Hospital Compare (www.hospitalcompare.hhs.gov). CMS contracted with L&M Policy Research (L&M) and its subcontractors to conduct formative research around the new outpatient measures and to develop and consumer test plain language displays.

Methods: L&M utilized an iterative research approach, conducting formative research to explore how consumers interpret and understand the new quality measures, with a particular emphasis on the concept of efficiency, followed by consumer testing of mock displays and language of the proposed measures. The research included focus group discussions and in-depth interviews with consumers, family caregivers, clinicians, and hospital-based quality improvement professionals. The team also convened a consultative workgroup, comprised of key stakeholders, to elicit suggestions for research questions and to provide feedback on the development of the measures.

Results: Participants had difficulty interpreting and using the measures to judge hospital quality. The research demonstrated that consumers do not perceive a choice in selecting hospitals; more simply they follow their doctor's advice or receive care based on their doctor's hospital affiliation. Participants also struggled with the concept of efficiency; some were suspicious that services being provided “efficiently” would be beneficial for the government but not for patients. Even when understanding the intended purpose of the measures, some believed that it is always better to have more tests, irrespective of the particular need. Also, participants considered the doctor, not the hospital, responsible for deciding which tests a patient needed.

Conclusions: Based on the research, feedback provided through the consultative workgroup, and in close collaboration with CMS, the L&M team developed plain language displays of the outpatient measures, which will be included on the Hospital Compare Website.

Implications for research and/or practice: The development of outpatient measures for public reporting posed several challenges, particularly with the introduction of the concept of efficiency as it relates to the provision of quality care. Findings point to the need to present new quality measures in a way that is understandable and meaningful to consumers, as well as in a credible fashion for clinicians, who have a direct stake in how information about their hospitals is conveyed.